Provider Demographics
NPI:1073124509
Name:MEDELA VIDA LLC
Entity Type:Organization
Organization Name:MEDELA VIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-331-0046
Mailing Address - Street 1:6020 E BROWN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4812
Mailing Address - Country:US
Mailing Address - Phone:602-428-0700
Mailing Address - Fax:
Practice Address - Street 1:6020 E BROWN RD STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4812
Practice Address - Country:US
Practice Address - Phone:602-428-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain